Provider Demographics
NPI:1790264695
Name:BASIRI, HOSSAIN
Entity Type:Individual
Prefix:
First Name:HOSSAIN
Middle Name:
Last Name:BASIRI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15090 N NORTHSIGHT BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-2609
Mailing Address - Country:US
Mailing Address - Phone:480-550-4747
Mailing Address - Fax:
Practice Address - Street 1:15090 N NORTHSIGHT BLVD STE 105
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-2609
Practice Address - Country:US
Practice Address - Phone:480-550-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2817I156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD07020536OtherDRIVER LICENSE